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Objective: To compare the long term outcomes of the two treatment options for navicular stress fractures: non-weightbearing cast immobilisation and surgical fixation.
Design: Retrospective case study.
Participants: Subjects aged 18 years and older who had been treated for a navicular stress fracture more than two years previously.
Main outcome measures: Questionnaire based analogue pain score and function score; tenderness on palpation; abnormality detected on computed tomography (CT).
Results: In all, 32 fractures in 26 subjects were investigated. No significant differences were found between surgical and conservative management for current pain (p = 0.984), current function (p = 0.170), or abnormality on CT (p = 0.173). However, surgically treated patients more often remained tender over the "N spot" (p = 0.005), even after returning to competition for two years or more.
Conclusions: Surgical fixation of navicular stress fractures appears to be as effective as conservative management over the longer term. However, there remains a small but measurable degree of pain and loss of function over this period. The value of using "N spot" tenderness as the sole clinical predictor of treatment success requires further investigation, as some patients remained tender despite successful completion of treatment and return to competition.
BACKGROUND: Navicular stress fractures of the foot often are difficult to diagnose and treat.
METHODS: Nineteen athletic patients seen from 1999 to 2003, were compared to a previously treated group of 22 athletes with similar injuries treated from 1994 to 1998. Based on the frontal plane CT images, a previously described classification system was used to assess the injury: type I dorsal cortical break; type II fracture extending into the navicular body; and type III fracture breaches two cortices. Nonoperative treatment was recommended for patients with type I injuries and open reduction and internal fixation (ORIF) were recommended for those with type II and III injuries. The time to return to activity and ability to return to competition were assessed, along with differences between fracture type and gender.
RESULTS: Return to activity (RTA) was 4.0 months for the entire group. RTA for type I (four injuries), type II (eight injuries), and type III (seven injuries) was 3.8, 3.7, and 4.2 months, respectively. Fifteen of 16 competitive athletes returned to full competition, including all who had ORIF.
CONCLUSIONS: Navicular stress fractures can take 4 months to heal with nonoperative or operative treatment. Surgery should be considered for more severe injuries, which can be assessed by CT scan.
I have a patient with suspected Navicular stress fracture. Anyone have any experience with this. I have the understanding that an x-ray will not pick this up, and bone scan is the most sensitive....Will a CT or MRI s then be needed to get an idea of the pattern of fracture before treatment and after treatement?
Hi Pigsney:
It always been my understanding that if you can, in fact, see a fracture line on plain films then it is NOT a stress fracture but a fracture. Regardless of the underlying cause. Much like a metatarsal fracture vs stress fracture. If one views a fracture line through a metatarsal is it proper to call this a “stress” fracture or is it more properly labeled a fracture? Then we can describe the fracture line itself (transverse, spiral oblique, etc....) I do not agree with the terminology of calling true fractures “stress” fractures merely because some non-direct traumatic forces were applied to the bone in question.
Bone scans are very helpful but do not rule out active periostitis.
In my opinion true stress fractures of the Naviclular are normally diagnosed clinically with verification by bone scan. It’s been my experience that as long as the patient decreases his/her activity and “the patient and the navicular are in the same room,” it will heal !!!!
Good luck
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
HMM
Okay, so no need for complete non-weightbearing with cast? One text book I was reading said this was necessary due to high tendency of non-union due to avascularity?
"HMM
Okay, so no need for complete non-weightbearing with cast? One text book I was reading said this was necessary due to high tendency of non-union due to avascularity?"
Hi Pigsny:
Well, again, if you are talking stress fracture, no. If you are talking a fractured Navicular, then probably. You didn't mention the age and general health of your patient nor what the actual fracture was other than calling it a "stress fracture".
My previous post was trying to point out this very problem with the "stress fracture" terminology. What is a stress fracture to one practitioner may be called something else by another.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Hey hey drsarbes
Healthy girl early/mid 20's ..... participates in aerobics 3 times a week and has been for over a year. No investigations completed as yet besides clinical so I don't know what type of fracture if any fracture at all. Treatment at the moment is strapping and rest from aggravating activity. Vague pain with excessive force placed on foot. Suspect it could be a fracture which has gradually happened over a period of time due to the forces placed on it from aerobics.
Hi Pigsney:
Sounds like it's not too serious. As long as she's responding to your present treatment and a little TLC no need to do anything else. You may want to evaluate her biomechanically. She may be in the over use category.
Good luck
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Navicular stress fractures in athletes are notoriously difficult to diagnose, resulting in an average delay in diagnosis of 4 months after the onset of symptoms. There are various reasons for this delay. Navicular stress fractures are characterised by an unspecific symptomatology combined with a paucity of physical findings. Furthermore there is difficulty in visualising stress fractures on plain radiographs, with only 33% of fractures visible on the initial films. There are several factors contributing to this : the vast majority (83%) of fractures are incomplete fractures at initial presentation and those that are complete are often non displaced and not visible because bony resorption at the fracture site requires 10 days to 3 weeks to occur. For this reason, 3-phase Tc99bone scan is the examination of choice, with almost 100% sensitivity after 72 hours. A favourable outcome can be expected with early diagnosis and proper management. Delayed diagnosis and subsequent improper management can lead to a poor outcome with adverse effects on the activities of the athlete. Treatment consists of 6-8 weeks in a non weight bearing cast for incomplete fractures and non displaced complete fractures. Surgical treatment consists of screw fixation with or without bone graft. Some authors advocate aggressive treatment of non displaced complete fractures. It is imperative to maintain a high index of suspicion when treating patients, especially sprinting athletes, who present with vague mid-foot or ankle pain associated with weight bearing.
Navicular Stress Fractures
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